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Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
EJON-C76QU7

FACILITY NAME
Twenty Sixth Avenue Home
SERVICE TYPES
140 Community Living
FACILITY LICENSE #
0982534
FACILITY ADDRESS
27134 26th Ave
FACILITY PHONE
(604) 856-6097
CITY
Aldergrove
POSTAL CODE
V4W 3N6
MANAGER
Daniel Penner

INSPECTION DATE
September 21, 2021
ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
4
ARRIVAL
10:30 AM
DEPARTURE
02:30 PM
ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Routine
# OBSERVED IN CARE

Introduction

Routine Inspection Report

An unscheduled routine inspection was conducted to assess compliance with the Community Care and Assisted Living Act (C.C.A.L.A.), the Residential Care Regulation (R.C.R.), and the relevant Director of Licensing Standards of Practice (D.L.S.P.). Evidence for this report was based on the licensing officer's observations, review of the facility records, and information provided by the facility staff at the time of inspection.

The following areas were reviewed:

- Licensing
- Physical Facility
- Staffing
- Policies and Procedures
- Care and Supervision
- Hygiene and Communicable Disease Control
- Medication
- Nutrition and Food Services
- Program
- Records and Reporting

As part of this routine inspection a facility risk assessment tool is completed. The risk assessment includes contraventions identified during the routine inspection, and a 3 year historical review of the facility's compliance and operation.

Contraventions
Previous Inspection -
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.

Observed Violations
PHYSICAL FACILITY, EQUIPMENT AND FURNISHINGS: 31760 - RCR s.35(1)(c) - A licensee must provide the following appropriately furnished and equipped areas: (c) secure, safe and adequate storage areas for cleaning agents, chemical products and other hazardous materials.
Observation (CORRECTED DURING INSPECTION): During inspection of the physical facility, it was observed that a cleaning agent was located on top of the laundry machine in an area that is accessible to persons in care. It was also observed in the kitchen area that a cupboard used to store cleaning agents was not secured.
Corrective Action(s): Please ensure that all cleaning agents and other chemical products are safely and securely stored at all times.
Date to be Corrected: Corrected at time of inspection.

NUTRITION AND FOOD SERVICES: 37040 - RCR s.62(2)(b) - A licensee must ensure that each menu provides (b) for each day, at least 2 nutritious snacks, with each snack containing at least 2 food groups as described in Canada's Food Guide.
Observation: In review of the facility's menu, for 3 days the evening snacks did not contain at least 2 food groups as described in the Canada's Food Guide.
Corrective Action(s): Please ensure that each menu provides at least 2 snacks per day, with each snack containing at least 2 food groups.
Date to be Corrected: October 8, 2021

RECORDS AND REPORTING: 39320 - RCR s.83(4)(a) - Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must (a) ensure that each person in care is weighed at least once each month.
Observation: In review of a person in care's weight records, it was observed that a monthly weight was not recorded for 3 seperate months within the past year.
Corrective Action(s): Please ensure that each person in care is weighed at least once each month.
Date to be Corrected: October 8, 2021


Comments

This Licensing Officer would like to thank the Manager and Staff for their assistance in completing this routine inspection.

The following was discussed:

- This Licensing Officer discussed the roles and responsibilities of the Medication Safety and Advisory Committee with the Manager as required by the Residential Care Regulations. The Manager stated that the MSAC meets every 6 months. This LO highly recommends that the MSAC meeting minutes includes the following issues/points of discussion to ensure the MSAC is meeting the regulatory requirements of Section 68 of the Residential Care Regulations:
(1) The MSAC must review the training and orientation for employees who store, handle or administer medications;
(2) The MSAC must review policies and procedures in respect of the safe and effective storage, handling and administration of medications; and
(3) The response and reporting of medication errors and adverse reactions to medications.

Please provide a response to Licensing by October 8th, 2021 as to how the identified items in this report will be addressed.

Please contact your Licensing Officer if you have any questions or concerns regarding this inspection report.

(Please note: this inspection report was written off-site and forwarded to the Licensee)

Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to LicensingNo action required
Due Date
Oct 08, 2021

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Click here for a description of each "Category" of violation displayed.